www.italk.org.uk 1

A psychological therapy service

Depression

A self help workbook

italk is provided by Solent Mind and Southern Health NHS Foundation Trust

Southern Health

2 www.italk.org.uk

ContentWelcome to italk How can we help you to overcome and manage

symptoms of depression? What is CBT? What is depression? Goal Setting

Types of Intervention Behavioural Activation Thought Challenging Problem Solving

Planning for the Future

Recovery Stories

Other resources

www.italk.org.uk 3

Welcome to italkThis booklet is designed to aid you in your recovery and help you to help yourself with the support of your practitioner. Step 2 of the italk service offers telephone based support to people who

are experiencing symptoms of anxiety and/or depression by using Guided Self Help.

Guided Self Help interventions are based on Cognitive Behavioural Therapy (CBT). A range of interventions are presented here and you will work through some of these interventions with one of our Psychological Wellbeing Practitioners (PWP). PWPs are specially trained to identify which of these approaches are best for your needs and deliver these CBT based interventions to help you to manage and overcome your particular difficulties.

Your PWP will introduce you to a range of tools and literature that you can work through in your own time between appointments. Through Guided Self Help you can gain a better understanding of the issues that are affecting you and will learn new skills to be able to make positive, practical changes. Guided Self Help strategies that we use at italk are evidence based and in line with NICE (National Institute Clinical Excellence) guidelines and recommendations.

Guided Self Help is a short-term intervention delivered in approximately 6 sessions, generally spread over several weeks. The sessions are booked for 20-30 minutes and the aim of them is to focus on reviewing your work between sessions and setting up tasks to be reviewed at the next one. To prepare for each of these sessions, you will also be asked to complete the questionnaires that you became familiar with during your assessment. These questionnaires are one of the ways we can measure your progress over time. You can find copies of these at the back of this booklet.

If at any point during the course of the sessions you feel treatment is not working for you, then let your PWP know so that other options can be explored. If you have any questions about the tasks discussed then ask your PWP for advice. Your PWP can also give you information about other services in your area that may be helpful.

4 www.italk.org.uk

How can we help you to overcome and manage symptoms of depression?

What is CBT?

Fortunately there are a number of ways, we can help you to overcome depression and low mood. These include:

Learning strategies that will enable you to become more active, re-establish routine and make a better use of your time

Learning how to challenge unhelpful thinking and see things in a more balanced way

Improving your problem solving abilities

Learning to acknowledge and notice your qualities and achievements

These strategies are based on Cognitive Behavioural Therapy (CBT).

CBT is a way of managing common mental health difficulties such as depression and anxiety by understanding and talking about:

how you think about yourself, the world and other people and how these thoughts might be affecting your emotions

how what you do, can have an impact on your thoughts and emotions.

CBT based interventions can help you to challenge and change how you think (Cognitive) and what you do (Behaviour). These changes can help you to feel better emotionally and break the vicious cycle of depression. The CBT approach focuses on the ‘here and now’. It looks for ways to improve your state of mind by making changes in the way that you do things or in the way that you think. By making changes in just one of these areas in the vicious cycle of depression, it can have a positive impact on the other areas that have also been affected following depressed mood.

www.italk.org.uk 5

What is depression?We all go through spells of feeling down in the dumps and gloomy, but when you’re depressed you feel persistently sad for weeks or months, rather than just a few days. The ways in which depression can have an impact on us varies from person to person but it is common to find that it interferes with our daily routines.

People often find that they lack the effort to do things such as household chores, hobbies, work, socialising, maintaining relationships and childcare related activities, as well as other activities. By avoiding effort, people experience relief, which in turn leads to more avoidance. However, this relief only happens in the short term, as in the long term this can make you feel worse and you may notice your mood becomes lower. See overleaf a 5 Areas Diagram demonstrating how different areas of our lives can change as a result of depression.

6 www.italk.org.uk

To help you to look at your personal difficulties in more detail, have a look at the blank ‘5 Areas Diagram’ to the right and try to fill it in based on your personal experiences and how you might be feeling right now.

Trigger:

Life situation, significant

event or problem.

MooD/eMoTion:

Depressed, low, sad,

hopeless, fearful or irritable.

PHysiCAl syMPToMs:

Lethargy, tiredness, poor

appetite or increased

appetite, disrupted sleep.

THougHTs:

“Everything I do always

goes wrong, people don’t

appreciate/like me.”

BeHAviours:

Avoid contact with others, reduced

activity levels, poor self care.

5 AreAs DiAgrAM:

www.italk.org.uk 7

Trigger:

MooD/eMoTion:

PHysiCAl syMPToMs: THougHTs:

BeHAviours:

8 www.italk.org.uk

goal setting

Before we can start to learn to apply these new strategies into your present life situation, we need to know what we want to achieve or how we would like things to be different from how things are currently. Making changes and learning new things can be challenging when we are feeling low and therefore is important that we start with small steps and build up from them. We can start the process by looking at making short term and long term goals. In general your goals would be directly linked to the problem statement that you create during your assessment. Your PWP will help you to review your problem statement in the session and you can reflect on your experiences and changes as they occur.

To help you in thinking about your goals and what you would like to achieve ask yourself the following questions: What is it that I am really struggling with at present?

When and where do I find things most difficult (i.e. work, home, when alone)?

Write your problem statement here:

Now that you have had an opportunity to work on your own ‘5 Areas Diagram’, you may have a better understanding of some of the unhelpful changes you have experienced recently. Next we can start to look at what your personal goals are and what you would like to achieve. Based on your personal goals, we can move on to selecting an intervention that could help you in the road to recovery.

www.italk.org.uk 9

To be most effective your goals should be SMART.

smart goals

SPECIFICEnsure your goals are as specific as possible. Include dates, times, resources etc. that you might need to achieve them.

MEASURABLEEnsure the goal you have set is capable of being measured. If not, think about how you can change it so that you can measure it.

ACHIEVABLEAsk yourself if your goals are achievable, and if your goals are short term, is it possible to achieve it in the next couple of weeks? If not, think about breaking it down.

REALISTIC Try to ensure that your goals are realistic in your life now. Will achieving the goals make a difference to you right now? Is it relevant? Is it fair to expect that of yourself? If not, try to adapt them.

TIME SPECIFICTry to set yourself a time by which you want to achieve your goals. If short term, this may be within the next week or two. If not, then go back to ‘achievable’ and think about how to adapt them.

short term goals

long term goals

10 www.italk.org.uk

routine activities

Housework, cooking, shopping, cleaning

Pleasurable activities

Going to the cinema, meeting up with a friend, reading a book, exercise

necessary activities

Arrange an MOT for your car, opening letters that have been piling up, paying a bill

Types of interventionBehavioural Activation

Behavioural Activation (BA) is an intervention that links directly to making changes in the ‘Behaviour’ box of your ‘5 Areas Diagram’. BA focuses on exploring the things that you have stopped doing or things you are struggling to do since your mood became low. By identifying what has changed, we can start to make a plan to restore some of the routine or structure you have lost. BA is a step by step process that helps you to make gradual changes in your daily routine by looking at three different types of activities; ROUTINE, PLEASURABLE and NECESSARY activities. Below, is a list of examples of typical activities that might belong to these activity categories.

www.italk.org.uk 11

Next, think about your own experiences and make a list of things you have stopped doing or things you are struggling to do based on the three different categories you just had a look at.

routine activities

Pleasurable activities

necessary activities

12 www.italk.org.uk

Now, thinking about the list you have created, try to put the activities in an order of difficulty to carry out from the LEAST DIFFICULT to the MOST DIFFICULT. The list will be personal to you, try to think about what task you might find most difficult to motivate yourself to do as opposed to the difficulty of the actual task.

least difficult

Medium difficulty

Most difficult

www.italk.org.uk 13

On the next page, you will find a diary. Take a look at the diary and put one or two tasks from each difficulty category into the plan. Alternatively you might want to start with the easier tasks and work up towards the harder ones. Remember to ensure that if you do select two tasks from the same category to place them on different days of the week, so that you have a balanced level of activities throughout and don’t get too overwhelmed on specific days.

TASK: After each week of completing the diary, take a bit of time to review your notes. Think about your achievements for that week, what were the positive aspects, difficulties or barriers to carrying out the tasks?

It is also helpful to rate your mood out of 10 each day , where a score of 0 is the lowest your mood could possibly be and 10 is the best your mood could possibly be. It could be helpful to review this with your PWP in your next session.

14 www.italk.org.uk

Mo

nd

ayTu

esd

ayW

edn

esd

ayTh

urs

day

Frid

aySa

turd

aySu

nd

ay

Mo

rnin

g

Aft

ern

oo

n

Even

ing

Co

mm

ents

www.italk.org.uk 15

Thought ChallengingThought challenging is based on the notion that our emotional states can be maintained by how we think. Some thoughts are ‘automatic’ and many of these can be ‘unhelpful’. Unhelpful automatic thoughts seem believable and real at the time they appear and they are often ones that would upset anybody. These types of thoughts have a very powerful impact in maintaining particular states of mood. Unhelpful automatic thoughts are often based on our assumptions of a situation, as opposed to the facts and the reality of the situation. Thought challenging is a process that helps us to examine and challenge our unhelpful thoughts, and it allows us to gain a more realistic and balanced way of thinking, in order to improve our mood.

There are three steps to the process of thought challenging and your PWP will support you through each stage.

Stage 1 - Identifying Thoughts

Stage 2 - Looking for the Evidence

Stage 3 - Reconsidering Thoughts

stage 1. identifying Thoughts

In order to be able to help you in identifying your thoughts, it is helpful to record a particular situation where you were feeling a particular emotion and try to identify what the emotion was. Try to give this emotion a rating of intensity from 0-100%, whereby 100% would be the most intense the emotion could be. Following this, try to capture the exact thoughts that went through your mind at the time of being in that situation and write these thoughts down on your thought diary. Once you have identified the thought/s, try to think about how much you believed those thoughts to be true at the time and give them a rating from 0-100%, whereby a rating of 100% would mean that you believe there to be no other explanation. See an example below.

situation

Where, who with, when

emotion

Rate the intensity of the

emotion from 0-100%

Thought

Rate how much you believed this

thought at the time from 0-100%

Sat watching TV with

my partner, not able to

concentrate, my mind filled

with thoughts

Sad 90%

Upset 70%

Frustrated 75%

“I am no fun to be around” 70%

“There is so much I need to do and I

just can’t find the energy” 75%

“I am useless” 90%

16 www.italk.org.uk

stage 2. looking for the evidence

Once you have identified and written down your thoughts on the thought diary, choose one thought to work on. Ordinarily this would be a thought you have given the highest belief rating, or a rating of 60% and above. We call this thought a ‘hot thought’ because in general the highest rated thoughts cause the most emotional distress. Once you have selected the thought you would like to work on, transfer this to the ‘Evidence Recording Sheet’ where we would then search and examine the evidence for and against this thought. Please remember the evidence should be based on facts, rather than your opinion. See an example below.

stage 3. reconsidering Thoughts

Now that you have identified your thoughts and looked for evidence for and against your thoughts, you can start to reconsider your thoughts based on the facts you have gathered. The idea is to come up with a revised thought, based on the evidence you gathered previously. See an example below:

My thoughts My belief %

“I am useless”

evidence for evidence against

-I failed my driving test

-I’ve had to access support for my low mood

-I’m signed off work

-I’m too tired to go to the gym

revised thought

Rate how much you believe the new thought

From 0-100%

emotion

Rate the intensity of the emotion from 0-100%

“I am just having a tough time at the moment,

there are plenty of things I have achieved in

my life”

50%

Sad 50%

Upset 40%

Frustrated 50%

www.italk.org.uk 17

Thought DiaryTry and keep a thought diary for yourself:

stage 1: identifying Thoughts

Now pick the hot thought, and have a go at challenging it:

stage 2: looking for the evidence

situation

Where, who with, when

emotion

Rate the intensity of the

emotion from 0-100%

Thought

Rate how much you believed this

thought at the time from 0-100%

My thoughts My belief %

evidence for evidence against

18 www.italk.org.uk

And finally, come up with a new revised thought and re-rate your feelings:

stage 3: reconsidering Thoughts

Every time the original thought comes back into your mind, repeat replacing it with the new revised thought. It will take practise for this technique to work. Over time you will find that the process comes more naturally to you.

revised thought

Rate how much you believe the new thought

From 0-100%

emotion

Rate the intensity of the emotion from 0-100%

Problem solving

Problems in our day to day lives can seem overwhelming and lead to difficulty in making decisions. Sometimes it can be helpful to explore the possible solutions to what can seem like very difficult or overwhelming problems, which is why we have included techniques for ‘problem solving’ in this booklet. Your PWP may suggest this technique for you and will guide you through the steps.

There are seven steps to problem solving:

Step 1: Identify the problem Step 2: Identify the possible solutions Step 3: Think about strengths and weaknesses Step 4: Select a solution Step 5: Make a plan Step 6: Carry out the plan Step 7: Review

Let’s look at each step in more detail. Your PWP will also talk you through each step in this worksheet.

www.italk.org.uk 19

step 1: Identify the problem. Your PWP will support you to identify a clear and specific problem to work on.

step 2: Identify the possible solutions. Begin by brainstorming every possible solution you can think of, no matter how impossible or ridiculous some of them may sound. Use a separate sheet if you need to.

step 3: Think about the strengths and weaknesses of each solution.

step 4: Choose a solution based on what you have found in step 3. What is realistically most likely to work for you?

step 5: Make a plan. This may have several stages of its own and you need to be specific. Your PWP will support you to think about what you need, who could help you, when you will need to do each step and where you may need to go.

20 www.italk.org.uk

step 6: Carry out the plan. It is helpful to use a diary to help with progress on your solution.

step 7: Review the plan. How did it go? Do you need a new plan or are you ready to problem solve a different area?

Now is a good time to review the progress that you have made with your PWP.Firstly, let’s look at those initial goals that you made:

Planning for the Future

short term goals

The goals I set were: Do I feel they have been met?

long term goals

The goals I set were: What can I do to keep heading in the right direction?

www.italk.org.uk 21

Now that you have come towards the end of your treatment it is important to look at ways to avoid things ‘slipping back’ to how they were before. Your PWP will support you to complete this relapse prevention and will review the plan with you during your final session.

It is natural to experience a lapse or relapse, particularly at stressful periods in our life because change can be challenging to maintain. A lapse is described as a one-off return to previous unhelpful behaviours e.g. avoiding a social event. A relapse is a return to a certain lifestyle e.g. persistently avoiding activities, returning to negative automatic thinking. Some people relapse many times before they maintain the changes they have made. Therefore it is helpful to learn about and use relapse prevention strategies to avoid returning to the initial vicious cycle we looked at using the ‘5 Areas Diagram’. Answering the questions below can be helpful in achieving this, so please have a go at filling out the table with your own examples which you can review and build on in your last session with your PWP.

Now that you have either made progress towards, or met these goals, let’s look at making some new ones, or using the new skills that you have learned.

goal (make sure it’s sMArT) How can i achieve this?

Short term

Longer term

22 www.italk.org.uk

What have i learnt about myself during my treatment sessions? Think back to the ‘5

Areas Diagram” if this helps.

Which helpful skills have i learnt that i can continue to use?

What are the barriers to me using these skills in the future? (e.g. time, my own thinking). How can I overcome these barriers?

What are some of the early signs that things may be slipping? Remember these

may be thoughts, behaviours, emotions or

body sensations. (You may wish to ask friends

and family as they often notice first).

Are there any particular situations or triggers that i need to plan ahead for?

everyone has the odd ‘bad’ day or two. What can i do on these days to help me?

if i am worried that things are slipping again, who can i contact to support me?

Think about friends, family, GP, or another

organisation.

reflections

www.italk.org.uk 23

recovery storiesPaul is a 45 year old father of two teenagers. His work role changed after a restructure at work which knocked his confidence, he began to feel low in mood and turned to italk for support.

Let’s have a look at Paul’s initial ‘5 Areas Diagram’ to get an understanding of the difficulties he was experiencing:

Trigger:

Work stress

MooD/eMoTion:

Low, stressed.

PHysiCAl syMPToMs:

Heart racing, hot and

sweaty, poor appetite,

poor sleep, tired.

THougHTs:

“I can’t cope.”

“I am useless.”

BeHAviours:

Withdrawal from hobbies

and social events,

decreased motivation.

24 www.italk.org.uk

Problem statement:

“Since the changes at work happened, it’s really knocked my confidence. I’ve been feeling really stressed and quite down at times. I have stopped doing my hobbies and I am finding it really difficult to sleep”.

goals:

“To have a better night’s sleep”“To reduce my stress levels”“To not feel so low”“To get back into my hobbies”

Paul was given the options of thought challenging or behavioural activation to work on using guided self help. He decided to choose behavioural activation, as looking at his ‘5 Areas Diagram’ he could see that there were a number of things that he has stopped doing, or avoided. He felt this was the best way for him to break the cycle and create one of wellbeing. Paul had also taken into account the research which supports the use of behavioural activation to successfully treat depression.

Paul’s list of activities in order of difficulty:

routine activities

Load dishwasherClean the bathroomWash the car

Pleasurable activities

FootballGym and circuits classSeeing friends at the pub quiz each week

necessary activities

Phone billCredit car billSort out car insurance

You can see that when he started doing less of his hobbies and social events, he began to feel worse and experienced more unhelpful negative thoughts.

With the help of his PWP, Paul identified the following problem statement and goals:

www.italk.org.uk 25

Mo

nd

ayTu

esd

ayW

edn

esd

ay

Mo

rnin

g

Load

dis

h

was

her

Aft

ern

oo

n

Lun

chti

me:

Pay

cr

edit

car

d b

ill

Even

ing

Get

car

in

sura

nce

q

uo

tes

Co

mm

ents

Felt

go

od

fo

r g

etti

ng

a

cho

re d

on

e b

efo

re w

ork

Dre

aded

p

ayin

g it

bu

t g

lad

it’s

do

ne

I fel

t re

ally

p

rou

d o

f m

ysel

f to

day

fo

r d

oin

g t

his

Wee

k o

ne

go

al

Each

wee

k Pa

ul r

ein

tro

du

ced

an

act

ivit

y to

his

life

. He

no

tice

d t

hat

by

incr

easi

ng

his

act

ivit

ies

his

en

erg

y an

d

con

fid

ence

als

o in

crea

sed

. In

tu

rn, o

ther

peo

ple

res

po

nd

ed m

ore

po

siti

vely

to

war

ds

him

.

Thu

rsd

ayFr

iday

Satu

rday

Sun

day

Load

dis

h

was

her

Foo

tbal

lW

ash

car

Cle

an h

alf

of

b

ath

roo

mPu

b q

uiz

I str

ug

gle

d

to g

et g

oin

g

bu

t fe

lt b

ette

r af

ter

do

ing

it

I fel

t a

bit

n

ervo

us

bu

t en

joye

d m

ysel

f

Foo

tbal

l was

g

reat

fu

n!I’m

gla

d I’

ve

man

aged

to

cl

ean

th

e ca

r ag

ain

26 www.italk.org.uk

Throughout your treatment you will be asked to complete these questionnaires before your appointments, so that your practitioner can assess the progress you are making and review the support and therapy that you receive.

PHQ-9 - Over the last 2 weeks, have you been bothered by any of the following problems? (Circle your answer)

Not at all Several days

More than ½

the days

Nearly every day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself in some way – or that you are a failure or have let yourself or your family down 0 1 2 3

7. Trouble concentrating on things , such as reading the newspaper or watching television 0 1 2 3

8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

9. Thoughts of being better off dead or of hurting yourself in some way 0 1 2 3

(out of 27)

GAD-7 - Over the last 2 weeks, have you been bothered by any of the following problems? (Circle your answer)

Not at all Several days

More than ½

the days

Nearly every day

1. Feeling nervous, anxious or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it is hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might happen 0 1 2 3

(out of 21)

www.italk.org.uk 27

Phobia scales Choose a number from the scale below to show how much you avoid the situations or objects listed. Then write the number in the box opposite the situation.

0 1 2 3 4 5 6 7 8

Would notavoid it

Slightlyavoid it

Definitelyavoid it

Markedlyavoid it

Alwaysavoid it

1. Social situations due to a fear of being embarrassed or making a fool of myself

2. Situations because of a fear of having a panic attack or other distressing symptoms (e.g. loss of bladder control, vomiting or dizziness)

3. Situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces driving or flying)

Work and social Adjustment scale People’s problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity (choose a number from the scale below and then write the number in the box opposite)

0 1 2 3 4 5 6 7 8

Nil Slightly Definitely Markedly Always

Workif you are retired or choose not to have a job for reasonsunrelated to your problem, please write N/A (not applicable)

HoMe MAnAgeMenT Cleaning, tidying, shopping, cooking,looking after home/children, paying bills etc.

soCiAl leisure ACTiviTies with other people, e.g. parties, pubs, outings, entertaining etc.

PrivATe leisure ACTiviTies Done alone e.g. reading, gardening, sewing, hobbies, walking etc

FAMily AnD relATionsHiPs Form and maintain close relationships with others,including the people that I live with.

28 www.italk.org.uk

Produced by italk, Hampshire’s Improving Access to Psychological Therapies (IAPT) service. Not to be reproduced without permission. italk 2014

other resources Citizens advice We help people resolve their legal, money and other problems by providing free, independent and confidential advicehttp://www.citizensadvice.co.uk/

Family lives (all aspects of parenting) free 0808 800 2222

Benefits advice www.gov.uk//benefits-advisor

Depression information www.depressionalliance.org

self-help resource site www.moodjuice.scot.nhs.uk

emotional support www.samaritans.org

self Help Books www.booksonprescription.org.uk

nHs Choices for further general information on all aspects of physical and mental health www.nhs.uk

DWB-V1